General Editor: Luiz Vialle

Authors: Ilya Laufer, JJ Verlaan (on behalf of AOSpine Knowledge Forum Tumor)

Metastatic tumors Thoracolumbar, unstable, low ESCC

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Glossary

General considerations

If applicable, all treatments should aim for the shortest time off systemic therapy.  Minimal invasive surgery (MIS) facilitates post-operative wound healing and recovery and is generally the treatment of choice where possible. Larger surgeries should be reserved for specific cases not eligible for less demanding surgery.

T2 through T5 symptomatic metastatic tumors should be treated using a posterior or posterior-lateral approach. The posterior-lateral approach provides greater exposure of the anterior part of the vertebra in order to facilitate anterior decompression and/or stabilization.

The choice between an anterior and posterior approach will be determined by the individual case and preoperative imaging, taking into account the location of the tumor and the destruction of the spine. With the introduction of percutaneous systems, the posterior approach has become the preferred technique.

Nonoperative treatment
Main indication Skill Equipment
Patient not fit for surgery due to medical comorbidities or very advanced metastatic disease. Basic surgical experience, no specialized skills Basic equipment only

Nonoperative treatment consists of radiotherapy, and if needed, brace stabilization to prevent ranges of motion that cause pain.

Posterior stabilization
Main indication Skill Equipment
Multi- or single-level disease or circumferential tumors Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Advantages

  • Multilevel osseous fixation
  • Avoidance of visceral organ manipulation

Disadvantages

  • Extensive paraspinal muscle dissection
  • Need for a longer construct compared to stand alone anterior approach
Posterior MIS
Main indication Skill Equipment
Multi- or single-level disease or circumferential tumors Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Advantages

  • Less soft tissue-traum
  • Decreased risk of wound complications
  • Less blood loss
  • Earlier rehabilitation
  • Multilevel osseous fixation
  • Avoidance of visceral organ manipulation

Disadvantages

  • Technically demanding
Kyphoplasty
Main indication Skill Equipment
Painful compression fractures secondary to metastatic spine tumors. Some specialized surgical experience Simple surgical and imaging resources

Contraindications

  • Extensive destruction of posterior cortex
  • Extensive destruction of posterior elements
  • High grade epidural tumor extension
Anterior corpectomy and stabilization
Main indication Skill Equipment
T6-L5 Single level vertebral body tumors Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Not recommended for T2-T5.

Contraindications

  • Extensive thoracic or abdominal treatment including radiation and prior surgery

Advantages

  • Anterior column support

Disadvantages

  • Risk of visceral or vascular injury
Combined anterior and posterior
Main indication Skill Equipment
Multilevel disease or circumferential tumors with extensive bone loss and long life expectancy Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Since most cases can be solved by either an anterior or posterior approach, the combined approach is only indicated in rare cases.

Advantages

  • Multilevel osseous fixation

Disadvantages

  • Extensive paraspinal muscle dissection
  • Risk of esophageal or vascular injury
  • Need for longer or multistage surgery
  • Overall high morbidity
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

V1.0 2019.01.06